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Friday, March 8, 2013

When Prescription Plans Try to Help

I received a snail-mail letter from the Clinical Services Division of Silverscript the other day, and I didn't know whether to laugh or sigh. So I did both.

Silverscript is a Medicare-approved Part D Sponsor. In other words, this company provides prescription drug plans to Medicare beneficiaries.

It also seems that they are attempting to provide clinical decision support to providers. In principle, this sounds like a reasonable idea. Older patients tend to take a lot of medications, and harmful interactions aren't uncommon.

In practice however, I've yet to come across any similar missive from a Part D plan that is actually helpful.

Next it says: "Reevaluating Anticholinergic Use in Benign Prostatic Hypertrophy (BPH)" and goes on to inform me that their records indicate my patient is receiving Spiriva and Tamsulosin. Their concern is that "anticholinergic agents in patients with BPH can counteract the effects of alpha-1-adreneric antagonists and alpha reductase inhibitors, leading to urinary obstruction and rentention."

[Yes, they misspelled "adrenergic".]

I'm then advised to consider slowly discontinuing the anticholinergic, changing the current medication to something less likely to precipitate urinary symptoms, or reducing the dose of the anticholinergic.

The letter concludes by acknowledging that "patient variables, unavailable to us, may make the current therapy appropriate for this individual," and I'm asked to respond via fax or mail, by completing a form regarding how I plan to act on the information they've sent. I'm also advised that I can call a toll-free phone number if I want a copy of the patient's medication profile.

Sigh.

The problems with this clinical decision support letter

Two key problems stood out to me:

The patient is no longer under my care. And hasn't been for the past 9 months. This means that I'm inappropriately being shown someone's protected health information. I assume it also means that the physician currently responsible the patient's medications didn't get this letter, but it's possible that Silverscript has sent letters to several of us.

There is no information on the likelihood of the potential interaction effect. This makes it hard to know how seriously to take this warning. Geriatricians do generally love to hate anticholinergics (they can cause delirium and worsen cognition), but we usually make an exception for the inhaled ones, since side-effects occur *much* less often than with oral anti-cholinergics.

In checking UpToDate's page on anticholinergics for COPD, I find a review of clinical research on urinary retention in BPH patients taking inhaled anticholinergics. In case you're wondering, case-control studies have found some increased risk of retention, but in a randomized trial of 6000 COPD patients (many of whom had BPH), the increased risk of urinary retention was too small to be statistically significant.

In general, I'd say that the overall likelihood that a patient would benefit from a prescriber receiving the above letter is basically nil. In practical terms, the significance of this possible interaction pales in comparison to the many other interactions and side-effects that older patients are routinely subjected to.

Also, how often can such a letter be useful if it's divorced from the context of the patient's conditions? It so happens that this patient has quite advanced COPD; last spring, he was just starting to require daily oxygen in order to get through his day. And, he has BPH and urinary symptoms, so that's another important quality of life issue.

Should we be bombarding providers with lots of little decision support tips?

Of course not. Providers, like all humans, can only pay attention to so many little decisions and distractions during the day. I know the prescription plan is trying to improve prescribing quality, but in truth, these kinds of letters are not helpful.

So I would certainly recommend that Part D plans, and the healthcare system overall, be thoughtful in deciding what they want to alert prescribers to, and how.

What would it take for these missives to be helpful? I'm not really sure, and when I take a quick look in the literature, I don't easily find anything studying the effect of these post-prescribing recommendation letters.

In general, it would be good if we could somehow prioritize which interactions are most important to identify and intervene on. One approach would be to take action on those interactions which are above a certain likelihood of harm threshold, instead of sending warnings for any potential interaction.

Next, I'd suggest that anyone who wants to send practicing physicians "educational information" start by running their proposed materials past a few real practicing physicians. We can probably make some useful pragmatic suggestions, and help ensure that the educational materials are better received. At a minimum, we could provide a reality check.

Last by not least, I hope these Part D plans will get better at identifying a patient's prescriber. I'm glad to receive this letter in that I can assume the patient is still alive, but I still think it's a bit wrong that I'm receiving his health information so many months later.

Summing it up

Pharmacy benefit programs routinely send providers "helpful" letters pointing out that some aspect of the patient's medication regimen should be reconsidered. I have yet to find any such letter useful.

In the case I describe above, the letter highlighted a potential interaction without providing me any guidance regarding how likely this interaction was. It turns out that the risk of harm was quite small, vastly outweighed by the benefits the patient is getting from the two medications. It also turns out that this patient hasn't been under my care for 9 months, yet I'm still receiving letters containing his protected health information.

Receiving many of these letters makes it difficult for practicing doctors to spot problems they *should* take action on. It would be nice to know if there is any evidence supporting the use of these kinds of letters from prescription drug plans. In the meantime, I suggest such letters include more information on the likelihood of harm, and that pharmacy plans get feedback from practicing doctors before sending them out en masse.